The Tennessee Department of Health has confirmed a case of measles in an Eastern Tennessee resident. Additional measles cases are expected to be confirmed. Susceptible persons may develop (or may have developed) measles illness following an unrecognized exposure to this case. Susceptible contacts of the known case may develop rash up to approximately May 8, 2019.

The patient visited several locations, including the Mapco at 200 Browns Ferry Road in Chattanooga. Anyone who was there on April 11, 2019 from 7:30-10 pm is advised to 1) check their vaccination status, 2) watch for symptoms of the illness if they are not immune to measles, 3) stay home and contact their healthcare provider if they develop measles symptoms.

Any patient with febrile rash illness or known to have been exposed to a confirmed case of measles should beimmediately masked and isolated in a room with a closed door or in an airborne infection isolation room; implement airborne precautions. Immediately report clinically suspected measles to our Epidemiology Department at 423-209-8190. Do not wait for laboratory testing to report.Also, immediately obtain the name of all persons who were in the waiting room, exam room or close proximity to this person. When possible, advise patients with a febrile rash illness or fever and cough to call before arriving at a medical facility so they can enter and be evaluated without exposing other patients. Normal disinfection measures can be used, but the room should remain out of service for two hours after the suspect patient leaves.

Epidemiology: Cases are infectious four days before rash onset through four days after rash onset. Average incubation period is 14 days (range 7-21 days) between exposure and rash onset. Measles is transmitted via respiratory droplets and is highly infectious. The virus may linger in the air of a room for up to two hours after an infectious person has left the area.

Clinical Symptoms: Begins with a prodrome of fever (up to 105°F) and malaise, cough, conjunctivitis, and runny nose (coryza). Small bluish-white spots with red bases may be seen on the buccal mucosa (Koplik’s spots). Rash onset is typically 3-7 days after onset of the prodromal symptoms, beginning on the face and spreading downward. Complications may include bacterial superinfections or encephalitis. Consider the possibility of measles when evaluating susceptible patients with an acute febrile rash illness, especially if the person has been in Eastern Tennessee since April 11, 2019.

Laboratory Testing: A nasopharyngeal or throat swab and serum sample should be obtained from any patient in whom measles is suspected. The throat swab should be collected and placed on viral transport media for PCR testing. The Epidemiology Department should be contacted immediately so labs can be sent to the State Public Health Laboratory. Commercial testing is reliable for IgG testing for immunity to measles. IgM testing in acutely ill patients may remain negative up to three days after rash onset.

Prevention: Vaccination is extremely effective, with two doses of MMR vaccine providing immunity to >97% of recipients. Ensure all patients ages 12 months and older are appropriately immunized and administer measles-mumps-rubella (MMR) vaccine to anyone over age 12 months who has not received MMR vaccine in the past 28 days and who does not have documentation of having received 2 doses of the vaccine.

Healthcare Personnel

1) Review documentation of presumptive evidence of immunity for all health care personnel who work in areas where there is potential for exposure to infectious patients.

Presumptive evidence of immunity to measles for health care personnel is limited to the following. Verbal reports of immunity are not acceptable.

• Written documentation of vaccination with 2 doses of live measles or MMR vaccine administered at least 28 days apart

• Birth before 1957. (This DOES NOT qualify for presumptive evidence of immunity in a community with an ongoing outbreak; such employees should have IgG+ confirmation or two doses of MMR).

Do not check IgG titers for any employees with two documented doses of MMR.

2) Health care personnel without presumptive evidence of immunity should be offered the first dose of MMR vaccine unless contraindicated.

In the event that a patient with measles presents to a facility, any healthcare facility personnel who lack presumptive evidence of immunity to measles meeting the above-listed criteria will be furloughed for 21 days from the last contact.

Additional Actions for all Healthcare Facilities:

1) Have an index of suspicion for measles, especially in the Eastern Tennessee area. Ensure triage, patient registration and ED staff are aware of the possibility of acutely infectious patients presenting to the facility.

2) If you have airborne infection isolation rooms (AIIR) or negative pressure rooms, ensure they are in working order.

3) Identify the best route to transfer patients from point of entry or ED to AIIR to minimize exposure to other persons (staff, patients, visitors).

What are your plans for the day, the week, the weekend? We often make time to think about upcoming events and plan activities so we can most enjoy them. But what if you could no longer make or share your own choices? Governor Bill Lee has proclaimed April 16, 2019 Healthcare Decisions Day in Tennessee to encourage Tennesseans to make plans for their healthcare in the event they cannot make or communicate their decisions.

From volunteering and mentoring to patient and physician advocacy, Dr. Colleen Schmitt brings her passion for serving the medical community to her new role as 2019 president of the Chattanooga-Hamilton County Medical Society.

“The major priority for the medical society here is to try and create a healthier community,” Schmitt said. “That supersedes really every other part of the strategic plan.”